As part of the first-line of diagnosis/management in the setting of an unknown ingestion, one could consider ordering a KUB, as a means of estimating the pill burden. This could potentially lead to a push for endoscopic removal of the ingested toxin/medication over other strategies that will be mentioned below.

The radiodensity of medications has been studied in the literature and the most recent data that I could find is from an article in 1998 in the Mayo Clinic Proceedings entitled “The radiodensity of medications seen on x-ray films” by Florez et al. They analyzed 50 prescription and nonprescription medications and all 50 medications were visible on plain x-ray films (though varied in their degree of radiodensity).

Methods of GI decontamination after ingestion

It is important to note that the overwhelming majority of adult patients with toxic ingestions have an uncomplicated course and require supportive care only.

There are no controlled clinical trials that show that the routine use of GI decontamination methods reduce morbidity or mortality.

The use of any of these methods is guided by the following:

Potential severity of poisoning

Presenting symptoms

Time from ingestion (usually only helpful within 1-2 hours)

Potential risk to the patient of the interventions that are being considered

General guidelines:

Protected airway (e.g., patient alert and protecting airway or intubated) is essential prior to initiation of any procedure! GI decontaminatinon should not be pursued if a patient is somnolent.

We will discuss two methods for GI decontamination that are often discussed in the literature and were mentioned this morning – activated charcoal and whole bowel irrigation.

Activated charcoal

Most likely to be of benefit within 1 hour of poison ingestion

Absorption is decreased by up to 95% if given within 5 minutes and up to 50-75% if given within one hour

Activated charcoal should not be used in the following situations:

Nontoxic ingestions

Patients who present after a time period when poison absorption is considered complete (e.g., typically > 2 hours after ingestions)

Aspiration is the most common concern that clinicians cite when choosing not to administer activated charcoal, however, overall the rate of aspiration is thought to be < 1 percent (from observational studies and retrospective chart reviews).

Whole bowel irrigation

Thought to be helpful in the following situations:

Toxic ingestions of sustained-release or enteric coated pill formulations – if started within 2 hours